Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. May 26, 2020; 8(10): 1950-1957
Published online May 26, 2020. doi: 10.12998/wjcc.v8.i10.1950
T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report
Chia Ching Lee, Chong Ming Yeo, Wee Khoon Ng, Akash Verma, Jeremy CS Tey
Chia Ching Lee, Jeremy CS Tey, Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Tan Tock Seng Hospital, Singapore 119228, Singapore
Chong Ming Yeo, Department of Medical Oncology, Tan Tock Seng Hospital, Singapore 308433, Singapore
Wee Khoon Ng, Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore 308433, Singapore
Akash Verma, Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore 308433, Singapore
Author contributions: Lee CC reviewed the literature and drafted the manuscript; Tey JCS and Yeo CM were the patient’s primary radiation and medical oncologists, reviewed the literature and contributed to manuscript drafting; Ng WK and Verma A were the procedurists who performed endoscopic interventions; all authors were responsible for the revision of the manuscript for important intellectual content and issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Jeremy CS Tey, MD, FRANZCR, MPH, Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Tan Tock Seng Hospital, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore 119228, Singapore. jeremy_tey@nuhs.edu.sg
Received: March 5, 2020
Peer-review started: March 5, 2020
First decision: April 1, 2020
Revised: April 1, 2020
Accepted: April 28, 2020
Article in press: April 28, 2020
Published online: May 26, 2020
Processing time: 81 Days and 3.3 Hours
Abstract
BACKGROUND

T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs.

CASE SUMMARY

A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m2 of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF.

CONCLUSION

This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.

Keywords: Esophageal cancer, Chemoradiotherapy, Fistula, Stenting, T4, Case report

Core tip: A trachea-esophageal fistula (TEF) may occur as a complication of treatment for definitive chemoradiotherapy for T4 esophageal cancer, particularly when treating with effective novel agents such as carboplatin-paclitaxel which may induce excellent tumor shrinkage. Because of the high morbidity and mortality associated with TEF, treatment intent is commonly switched from curative to palliative. The successful treatment in this case suggests that patients who develop TEF during treatment should carry on completing the planned treatment after discussion of potential benefits and risks. Excellent treatment responses may be obtained and the TEF may resolve completely.